Impact of COVID-19 on the surgical volume of general surgery residents as main surgeons in a National Training Program in Costa Rica: A cross-sectional study.

ABSTRACT: To quantify the impact of coronavirus disease 19 (COVID-19) on the surgical volume of residents' medical practice in Costa Rica's General Surgery Residency Program.The COVID-19 pandemic has caused a significant disruption in people's lives. Health systems worldwide have been forced to adapt to the new normal, which has posed a challenge for medical residency programs, especially in the surgical field.This transversal study includes the surgical records of all residents of the General Surgery program who worked as main surgeons at the Mexico Hospital of the Costa Rican Social Security between December 23, 2019, and June 25, 2020.As main surgeons, a total of 10 residents performed 291 pre-pandemic surgeries and 241 pandemic surgeries.When comparing the distribution of procedures performed by residency levels, it is observed that the postgraduate year -2 increased the number of procedures performed during the pandemic period (pre-pandemic 19% vs pandemic 27%, P = .028). There was no statistically significant difference between the pre-pandemic and pandemic periods in the remaining levels.When comparing the procedures by unit, a statistically significant decrease was observed in the Endocrine-Abdominal Wall Unit (pre-pandemic 18.3% vs pandemic 5.4%, P < .001). Conversely, a statistically significant increase was identified in Surgical Emergencies Unit procedures (40.0% vs post 51.7%, P = .007). No statistically significant differences were observed in the remaining the Units.The COVID-19 pandemic had no statistically significant effect on surgeries performed by residents of the General Surgery Residency Program as main surgeons in a national training center in Costa Rica. The Department's timely measures and pro-resident attitude were the key reasons for the above results.

Prevalence study of intermittent hormonal therapy of Prostate Cancer patients in Spain.

Background: Although intermittent androgen deprivation therapy was introduced many years ago to improve patients' quality of life with the same carcinologic efficiency as continuous hormonal therapy, recent data suggest that those patients could be overtreated. This study aims to estimate the prevalence of prostate cancer patients receiving intermittent androgen deprivation therapy in Spain. Methods: A retrospective, longitudinal study was conducted using electronic drug dispensation data from four Spanish autonomous communities, which encompass 17.23 million inhabitants (36.22% of the total population in Spain). We estimated intermittent androgen therapy use (%IAD) and the prevalence of patients under intermittent androgen therapy (P IAD) overall and stratified by region. Other outcome variables included the pharmaceutical forms dispensed and the total direct annual expenditure on androgen deprivation therapy-associated medications. Results: A total of 863,005 dispensations corresponding to a total of 65,752 men were identified, treated with either luteinizing hormone-releasing hormone (LHRH) analogues (353,162) administered alone or in combination with anti-androgens (509,843). Overall, the mean (±SD) age of the patients was 76.9 (±10.4) years. Results revealed that the mean annual P IAD along the study was 6.6% in the total population studied, and the overall %IAD during the five-year study period was 5.6%. The mean cost of hormonal therapy per year was 25 million euros for LHRH analogues and 6.3 million euros for anti-androgens. Conclusions:  An important proportion of prostate cancer patients in Spain could benefit from intermittent androgen therapy during the study period while avoiding overtreatment harms associated with continuous hormonal therapy.

Robotic-assisted Unicompartmental knee Arthroplasty optimizes joint line restitution better than conventional surgery.

PURPOSE: To compare joint line restoration after unicompartmental knee arthroplasty (UKA) between conventional and robotic-assisted surgery. Previous studies have shown that joint line distalization can lead to higher failure rates. The hypothesis was that robotic-assisted UKA is associated with less femoral component distalization and a precise tibial cut, which allows a more anatomical restitution of the knee joint line. METHODS: Retrospective cohort study of patients undergoing medial or lateral UKA between May 2018 and March 2020. Preoperative and postoperative radiologic assessment of the joint line was performed by two observers, using three different methods, one for tibial slope and one for tibial resection. Robotic assisted UKA and conventional UKA groups were compared. RESULTS: Sixty UKA were included, of which 48 (77.42%) were medial. Robotic-assisted UKA were 40 (64.52%) and 22(35.48%) were conventional The distalization of the femoral component was higher in the conventional group despite the method of measurement used In both Weber methods, the difference was statistically different: Conventional 2.3 (0.9 to 5.6) v/s Robotic 1.5 (- 1.1 to 4.1) (p =0.0025*). A higher proportion of patients achieved a femoral component position ≤ two millimeters from the joint line using robotic-assisted UKA compared to the conventional technique . No statistical difference between robotic-assisted and conventional UKA was found in tibial resection and slope. CONCLUSION: Robotic-assisted UKA shows a better rate of joint line restoration due to less femoral component distalization than conventional UKA. No difference was found in the amount of tibial resection between groups in this study. LEVEL OF EVIDENCE: III.

Impacto del cambio de presentación del trastuzumab para la Seguridad Social de Costa Rica, estudio de minimización de costos / Impact of the change of presentation of the trastuzumab for the Social Security of Costa Rica, cost minimization study

Resumen Objetivo: dado que en este momento está disponible a nivel de la Seguridad Social Costarricense tanto trastuzumab para administración intravenosa como para administración subcutánea, y que la presentación para administración subcutánea ha documentado ser no inferior a la intravenosa, resulta pertinente contar con un estudio de minimización de costes que permita documentar cuál de las formulaciones resulta más conveniente mantener en el sistema público de salud, con base en criterios de eficiencia de la intervención. Métodos: se desarrolló un estudio que evaluó desde la perspectiva financiera de la Seguridad Social de Costa Rica, dos opciones diferentes de aplicación del trastuzumab en pacientes con cáncer de mama. Los procedimientos relacionados fueron identificados y documentados para los dos tipos de aplicación del tratamiento intravenosa y subcutánea. Ambas opciones de tratamiento se basaron en esquemas de diecisiete dosis, con la estimación de los suministros y el tiempo del profesional sanitario para cada posibilidad. El análisis incluyó la evaluación desde la perspectiva del paciente. Resultados: la evaluación económica del procedimiento de administración para ambas alternativas evidenció que la opción subcutánea tenía un costo de aplicación de $ 78,6 y $ 467,34 para la opción intravenosa. Desde la perspectiva financiera, la opción subcutánea constituye la alternativa con un costo menor: $ 4000,00 por tratamiento por paciente, y desde la perspectiva de este, implica un 45,0 % menos de tiempo por sesión de tratamiento por paciente, que en la opción intravenosa. Conclusiones: la formulación de trastuzumab subcutánea evidenció una reducción sustancial de tiempo y costo en comparación con la presentación intravenosa en el sistema de Seguridad Social Costarricense.

Abstract Objective: Given that at this time is available at the Costa Rican Social security both trastuzumab for intravenous as for subcutaneous administration, and that the presentation for subcutaneous administration has documented to be not inferior to the intravenous. It is relevant to have a study of cost minimization to investigate what formulation is more convenient to maintain in the public health system, based on criteria of efficiency of the intervention. Methods: A study was developed to evaluate, from the financial perspective of the Social Security of Costa Rica, two different options of application of trastuzumab in patients with breast cancer. The related procedures were identified and documented for the two types treatment application. Both treatment options were based on seventeen dose schemes, with the estimate of supplies and the time of the health professional for each possibility. The analysis also included the evaluation from the patient's perspective. Results: The economic evaluation of the application procedure for both alternatives evidenced that the subcutaneous option had an application cost of $78.6 and $467.34 for the intravenous option. From the financial perspective the subcutaneous option constitutes the alternative with lower cost, with a cost around $4000.0 by treatment per patient, and from the patient perspective implies a 45.0% less time for session than then intravenous option. Conclusions: Trastuzumab subcutaneous formulation evidenced a substantial time and cost reduction in comparison with the intravenous formulation in the Costa Rican Social Security System.

Ascariasis biliar: caso clínico pediátrico reportado en Hospital General Enrique Garcés / Biliary ascariasis: pediatric clinical case reported in Hospital General Enrique Garcés

Áscaris lumbricoides, nemátodo frecuente en la población infantil, relacionado con situaciones socioeconómicas bajas y condiciones higiénicas desfavorables. El ciclo de vida del parasito inicia con la ingesta de huevos embrionados, tras esto desempeña un período hístico-tisular y transalveolocapilar, posteriormente alcanza el intestino delgado como parásito adulto. En ocasiones migra a diferentes sitios causando complicaciones, destacando la migración a vía biliar provocando colecistitis parasitaria. El siguiente caso trata de un adolescente de 12 años 9 meses que consulta por dolor abdominal localizado en epigastrio y cuadrante superior derecho. Es ingresada en el Hospital General Enrique Garcés de la ciudad de Quito, Ecuador donde se evidencia en ecografía la presencia de Áscaris lumbricoides en el interior de la vesícula biliar. Se realiza manejo clínico administrando antihelmíntico. Dos días posterior a su ingreso y culminado el tratamiento se solicita control ecográfico sin evidenciar la presencia del parásito

Ascaris lumbricoides is a frequently nematode in children associated with low socio-economic situations and unfavorable hygienic conditions. The life cycle of the parasite starts with the intake of embryonic eggs, then it plays an hyshc-hssue period and trans-capillary period. Subsequently reaches the bowel intestine as anadult parasite. Sometimes they migrate to different places causing complications, including migration to bile duct causing parasitic cholecystitis. The following case is a boy of 12 years 9 months old consulting for abdominal pain located in epigastrium and right upper quadrant. He was hospitalized in the General Hospital Enrique Garces in the city of Quito ­ Ecuador evidenciating the presence of on Ascaris lumbricoides in the interior of the gallbladder in the ultrasound. Antiprotoozarios were given. Two days after finishing the treatment, we requested a control ultrasound without observing the parasite

Intermittent androgen deprivation therapy: recommendations to improve the management of patients with prostate cancer following the GRADE approach.

PURPOSE: The purpose of this study was to provide evidence-based recommendations of intermittent androgen deprivation therapy (IADT) compared with continuous androgen deprivation therapy (CADT) for men with prostate cancer (PCA). METHODS: We conducted a comprehensive search in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and ECONLIT, from the database inception to December 2017. We adhered to the Grading of Recommendations, Assessment, Development and Evaluation framework to assess the quality of the evidence and to formulate recommendations. RESULTS: We included one systematic review with 15 trials as well as three additional studies that assessed IADT versus CADT, all of them focused on PCA patients in advanced stages. The findings did not show differences for critical and important outcomes, including adverse events. Trials reported the benefits of IADT in terms of selected domains of health-related quality of life, although with high heterogeneity. Evidence quality was considered moderate or low for most of the assessed outcomes. We identified a patient preference study reporting a high preference for IADT, due to issues related to quality of life, general well-being, and side effects, among others. We did not identify economic studies comparing these regimes. We formulate four recommendations: one no-recommendation, one conditional recommendation, and two good practice points. CONCLUSION: For men in early stages of PCA, it is not possible to make any recommendation about the preferable use of IADT or CADT due to the lack of available evidence. For men in advanced stages of the disease, an IADT should be considered as soon as clinically reasonable (weak recommendation and low certainty of the evidence). Clinicians should discuss the risks and benefits of IADT and CADT with their patients, taking into account their values and preferences.

Epidemiología de la candidemia en el Hospital México / Candidemia and it's Epidemiology at Hospital México

Justificación y objetivos:las infecciones invasivas por Candida son frecuentes y de alta mortalidad en la práctica clínica. Existe poca información publicada al respecto en el país. Estudio retrospectivo y observacional que pretende aportar conocimiento novedoso sobre la epidemiología local de la candidemia.Métodos:se incluyó 136 pacientes mayores de 17 años en su primer episodio de candidemia, internados en el Hospital México, entre 2007 y 2010. Se realizó un análisis descriptivo y temporal, se evaluaron los factores asociados con C. parapsilosis y con la sobrevida a 30 días.Resultados:se detectó en promedio 34 episodios por año (rango 27 a 51), la incidencia acumulada fue de 1,1 casos/1000 admisiones. Las especies de Candida no albicans constituyeron el 62% de las levaduras aisladas. Exceptuando 2009, C. parapsilosis fue la especie predominante en 3 de 4 años estudiados (41%), seguida por C. albicans (38%). Se demostró una fuerte asociación entre la candidemia por C. parapsilosis, la presencia de catéter venoso central (OR=19,6, IC95%: 2,6 a 403,8, p<0,001) y el uso de nutrición parenteral (p=0,014). La mortalidad a 30 días fue del 46%. C. albicans mostró la mortalidad más alta y C. parapsilosis, la más baja. Los pacientes que no recibieron tratamiento antifúngico presentaron una probabilidad significativamente mayor de morir.Conclusiones:la elevada incidencia de candidemia por C. parapsilosisestá directamente relacionada con los catéteres venosos centrales y el uso de nutrición parenteral; su marcada reducción en la frecuencia durante 2009, merece ser investigada para dilucidar los factores que provocaron este cambio.

Background:Invasive Candida infections are frequent and exhibit high mortality in clinical practice. There are few published data in our country. This retrospective observational study intends to provide new knowledge about the local epidemiology of candidemia.Methods:136 patients older than 17 years were included when they had their first episode of candidemia during hospitalization at the Hospital Mexico, in the time period between 2007 and 2010. Descriptive and temporal analysis was performed and the risk factors associated with C. parapsilosis and survival were evaluated.Results:An average of 34 episodes of candidemia were recorded per year (range 27-51) and the cumulative incidence was 1.1 cases/1,000 admissions. The non-albicans Candida species accounted for 62% of the isolated yeasts, C. parapsilosis (41%) was the predominant yeast isolated in 3 out of the 4 years analized, except for 2009, followed by C. albicans (38%). Strong association between C. parapsilosis bloodstream infection, the presence of a central venous catheter (2.6 to 403.8, p <0.001 OR = 19.6, 95% CI) and use of parenteral nutrition (p=0.014) was established. The 30-day mortality was 46%, with C. albicans displaying the highest and C. parapsilosis the lowest. Patients who did not receive antifungal treatment had significantly higher mortality.Conclusions:the unusually high incidence of candidemia due to C. parapsilosis is directly related to the use of central venous catheters and parenteral nutrition; the marked reduction observed in 2009 needs further investigation to find out the causes of this change.